Health & Medicine

Got a health care grievance? There’s a place to complain

Your health insurance company denied your treatment. Or it won’t provide the prescription drug you need. Or you’ve got a billing dispute. Or your longtime doctor was dropped from your health plan.

When you’ve got a complaint about health care, where are you gonna go? The MyPatientRights.org site is one starting point.

Launched last summer by the California Chronic Care Coalition, a group of more than 30 consumer health organizations, it’s intended to provide an easy link to the state Department of Managed Health Care, which handles consumer complaints with the state’s 122 licensed health plans.

“I’m getting calls from people who are frantic,” said Liz Helms, the coalition’s president and CEO. “Things have happened to them, such as they lost their doctor or they don’t know what to do about getting billed hundreds of dollars for out-of-network doctors. I had one man call who had a heart transplant and couldn’t get his anti-rejection medications. There are some crazy stories.”

Too often, Helms said, consumers have no idea where or to whom they should lodge a grievance. She said the site, which has had 300,000 visitors in less than a year, is not a criticism of the state’s complaint process, but an effort to help consumers navigate the system more easily. “We have a very complex (health care) system in California,” Helms said, noting that state departments of insurance, managed care and Medi-Cal each handles different aspects of health care. “They don’t know they have a place to go.”

That place is the state Department of Managed Health Care, which says its help center assisted nearly 1.6 million Californians with health-related problems since launching in 2000. Last year, the help center received more than 102,000 requests for assistance.

While it’s “disturbing” that consumers continue to have trouble “getting the care they need or getting billed for services they shouldn’t have to pay for, that’s why we exist,” said department director Shelley Rouillard.

Last year, consumer requests for help jumped by 60 percent compared with 2013, largely because of the implementation of the Affordable Care Act, according to the department. Most of the 7,940 complaints filed in 2014 were in three categories: enrollment issues (28 percent), benefits/coverage (24 percent) and financial/billing (21 percent).

The Affordable Care Act “completely blew up activity” at the department’s help center, Rouillard said, as many consumers new to the health care system encountered problems finding doctors or accessing treatment. While 2015 numbers have not yet been released, she does not expect the level of complaints to decline.

Either online or by phone, California consumers can lodge a wide range of health care-related complaints, such as: being denied certain medicines or treatments; having to wait too long for a referral, test or appointment; being sent home from the hospital too soon; having a problem with a bill, co-pay or claim; being unable to obtain services in their language; having doctors or hospitals dropped from a health plan. There’s even a customer-service category for “attitude/service” of providers and health plans.

Staffers help sort out varied issues, some on an emergency basis, such as when a patient’s family feels he or she is being released too early after surgery.

A separate avenue of complaint becomes available when your health plan denies, delays or modifies a treatment or medical procedure. In those instances, you can request an “independent medical review” or IMR, through the state Department of Managed Health Care. Independent doctors will review your case within seven to 30 days, depending on the urgency. According to the department, in about 60 percent of cases, the original denial is overturned and patients are granted the procedure or treatment they requested.

The IMR process does not apply to Medicare enrollees or workers’ compensation claims.

Overall, Rouillard said, the first place consumers should go with a health care-related problem is their own health plan. “If they don’t get a satisfactory response within 30 days, call us,” she said. “That’s why we’re here.”

Claudia Buck: 916-321-1968, @Claudia_Buck

Got a health care complaint?

First, contact your health care plan or physician’s office, either by phone, email or letter. Ask for the customer service department. If the issue isn’t resolved, you can file a complaint with the state Department of Managed Health Care. Call 888-466-2219 or file an online complaint at HealthHelp.ca.gov. Complaint forms are available in 13 languages.

If you need help filing a DMHC complaint, contact the Health Consumer Alliance, a group of free legal services centers covering all 58 counties. To find the nearest center, call 888-804-3536.

In addition, if you’re denied a specific medical treatment or procedure, you can request an Independent Medical Review (IMR) from the DMHC. Independent physicians will review your case within seven to 30 days. (IMRs are not available for Medicare or workers’ compensation issues.)

For help with Medicare problems, contact the Health Insurance Counseling and Advocacy Program (HICAP) at 800-434-0222.

Your health care rights

By law, every Californian is entitled to certain rights, including:

  • Have an appointment when you need one, including with a specialist. (For non-urgent issues, the wait time must not be longer than 10 business days for a primary care doctor; 15 business days for a specialist. For urgent issues that don’t require prior approval, you must be seen within 48 hours.)
  • Get a second medical opinion.
  • Request continuity if your doctor or medical group leaves your health plan.
  • Get services in your language.
  • Know why your plan denies a service or treatment.
  • Get a written diagnosis of your health problem.
  • Receive treatment for certain mental health conditions (major depression, anorexia, autism, schizophrenia, etc.).
  • File a complaint or seek an Independent Medical Review.
  • Keep your medical records private.

Source: California Department of Managed Health Care, healthhelp.ca.gov

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